Marta Martinez Morales says she can't afford insurance, but she comes to the Meliheh Free Clinic to get treatment for her diabetes.

Andrea Smardon

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As governor Gary Herbert weighs a decision on whether to extend Medicaid coverage to more low-income Utahns, a group of healthcare leaders appointed by the state has spent the summer exploring the options. Their findings will be presented to the governor at his health summit next week. Among those options, is to expand charity care in the state. KUER looks at what forms of charity care already exist in Utah, and whether this model could be a realistic alternative to expanding Medicaid.

On a morning at the Meliheh Free Clinic in South Salt Lake, a couple of young boys play on the floor while a half dozen men and women wait quietly for their names to be called.

“We see up to a hundred patients a day,” says charge nurse Stacey Lake, one of the few paid staff. Most of the doctors, assistants, translators, and specialists are volunteers.

This clinic operates without any federal funds. It was started with the support of one major benefactor, and relies on foundations and individual donations. Lake says the patients they serve cannot afford insurance. Without a free clinic like this, their only option would be the emergency room. In fact, the clinic was started by a group of E-R doctors for this reason.

“We have a lot of patients that prolong getting care because they think it’s going to cost them, and I’ve had patients come in in the middle of cardiac arrest, not thinking that they could afford going to the hospital,” Lake says. “They think they can’t afford to get care, so they just don’t get care.”

The staff at Meliheh Free Clinic try to serve as many patients as they can, but they have a six-month waiting list. It’s just one example of a wide variety of charity care that goes on around the state. It ranges from a private practice doctor waving a fee, to a mobile clinic offering services for free or low cost, to a hospital network that lets patients pay on a sliding scale depending on income. Conservative leaders in Utah see charity care as an appealing alternative, and want to expand it to serve more of the uninsured. Stan Rasmussen is Director of Public Affairs for the conservative think tank Sutherland Institute.

"We as human beings can and should be attentive to the needs of each other, and should not have to rely on mechanisms of government." - Stan Rasmussen, Sutherland Institute

“We feel that healthcare entitlements are impersonal, inefficient, and expensive, and that charity care builds community, costs less, and is more efficient,” Rasmussen says. “We as human beings can and should be attentive to the needs of each other, and should not have to rely on mechanisms of government.”

“I think in a utopian society, that might be a realism, but healthcare is run as a commodity, and healthcare is expensive,” says Alan Pruhs, Executive Director of the Association for Utah Community Health, which runs low cost clinics around the state funded in part with federal grants.

“There are costs to provide healthcare. If you were to look at the costs associated with Medicaid, I’m not quite sure how you cover that charitably,” Pruhs says.

If the state were to expand Medicaid coverage under the Affordable Care Act, the federal government would pick up 100 percent of the tab until 2017. But after that period, the state would have to pick up 10 percent. Over the first decade, the cost to the state could be more than $200,000,000. But expanding charity care to cover all the needs of the uninsured would come at a significant cost as well. The Sutherland Institute estimates the upfront costs of creating a comprehensive charity care system would be about 1 billion dollars. Pamela Atkinson – a well-known advocate for the poor - is not sure that Utah’s already generous donor population can support that.

“I think it would be very hard for people to decide – do I contribute and donate to this fund that has been set up for healthcare, or do I continue to donate to the various other charities around the nonprofits that serve homeless and low income people?” Atkinson says.

Then there is a question of how much donated time healthcare professionals can offer. Bountiful family physician Ray Ward points out that there is already a shortage of primary care doctors. Beyond that, he says, physicians are only a small part of the healthcare system. Charity care may not cover tests, labs, or prescriptions.

“Charity care means whichever group chooses to provide charity care does it, but it is not all put together in a system, and that has been my experience trying to work with it,” Ward says. “I can get a little bit here, I can get a little bit there. It falls through the cracks over here. The thing that worked last time, doesn’t work this time. So the patient goes without. Or the patient doesn’t come see me in the first place because they can’t afford to come in.”

While healthcare providers, lawmakers, and pundits debate, those who are uninsured confront the realities of what charity care offers, and what it doesn’t.

Laurie Spencer and her son Garrett are waiting anxiously in the lobby of Midtown Community Health Center in Ogden. Garrett is 33 years old, doesn’t have health insurance, and has been healthy his whole life, but, Laurie says, that’s suddenly changed.

“He’s extremely anemic, and we’re very, very concerned. He’s lost 50 pounds,” Laurie says. “They’ve ruled out leukemia. But now we’ve got to have EDG’s and colonoscopies and they’re setting us up today with a social worker to get him set up on some type of Medicaid or something, I don’t know – we’ve never done this before. This is our first experience of ever having to ask for help.”

Garrett Spencer lives with his parents, works part time, and only brings in about $6000 a year. So far, the Spencers have gotten a pretty deep discount at the health center, paying just two $25 co-pays.

“We’re just thankful that we have doctors that are willing to do what they can with what they’ve got,” Garrett says.

Laurie Spencer says she’s grateful for what they’ve received, but worried about what’s to come, and she wants some kind of health insurance for her son.

“It doesn’t matter how old your kid is, you want to know if they’re going to be OK,” Laurie says as she begins to sob. “I’m sorry I don’t mean to get emotional. We’re grateful. We’re hoping that we’ll get him on some kind of long term care because if it is something real serious then you know you have to get it taken care of. We’re not leaving the hospital until it’s fixed.”

What should happen for Garrett Spencer? That’s the question for state lawmakers. Should they organize and expand charity care so that Garrett could get the continuous and specialty help he will likely need? Should they expand Medicaid to cover single adults living at the poverty level? Or should they pursue a different option all together? In the meantime, how the uninsured will be cared for – and who will pay for it – remains an open question in Utah.

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